Physical Examination for the Acute Care Setting - RN.com · Her instructor experience includes...

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Focused Physical Examination for the Acute Care Setting

This course has been awarded one (1.0) contact hour.

This course expires on September 13, 2017.

Revised: September 13, 2014

Copyright © 2004 by AMN Healthcare in association with Interact Medical.

Reproduction and distribution of these materials is prohibited without an RN.com content licensing

agreement.

RachelJ

RN


Conflict of Interest and Commercial Support

RN.com strives to present content in a fair and unbiased manner at all times, and has a full and fair disclosure

policy that requires course faculty to declare any real or apparent commercial affiliation related to the content

of this presentation. Note: Conflict of Interest is defined by ANCC as a situation in which an individual has an

opportunity to affect educational content about products or services of a commercial interest with which

he/she has a financial relationship.

The author of this course does not have any conflict of interest to declare.

The planners of the educational activity have no conflicts of interest to disclose.

There is no commercial support being used for this course.

Acknowledgements

RN.com acknowledges the valuable contributions of…

….Nadine Salmon, MSN, BSN, IBCLC the Clinical Content Manager for RN.com. She is a South African trained

Registered Nurse, Midwife and International Board Certified Lactation Consultant. Nadine obtained an MSN at

Grand Canyon University, with an emphasis on Nursing Leadership. Her clinical background is in Labor &

Delivery and Postpartum nursing, and she has also worked in Medical Surgical Nursing and Home Health.

Nadine has work experience in three countries, including the United States, the United Kingdom and South

Africa. She worked for the international nurse division of American Mobile Healthcare, prior to joining the

Education Team at RN.com. Nadine is the Lead Nurse Planner for RN.com and is responsible for all clinical

aspects of course development. She updates course content to current standards, and develops new course

materials for RN.com.

...Kim Maryniak, RNC‐NIC, BN, MSN. Kim has over 22 years staff nurse and charge nurse experience with

medical/surgical, psychiatry, pediatrics, and neonatal intensive care. She has been an educator, instructor, and

nursing director. Her instructor experience includes med/surg nursing and physical assessment. Kim graduated

with a nursing diploma from Foothills Hospital School of Nursing in Calgary, Alberta in 1989. She achieved her

Bachelor in Nursing through Athabasca University, Alberta in 2000, and her Master of Science in Nursing

through University of Phoenix in 2005. Kim is certified in Neonatal Intensive Care Nursing and is currently

pursuing her PhD in Nursing. She is active in the National Association of Neonatal Nurses and American Nurses

Association. Kim’s current role in professional development includes nursing peer review and advancement,

teaching, and use of simulation.

…Robin Varela, RN, BSN, and Lori Constantine MSN, RN, C‐FNP, the original course author.


Purpose & Objectives

The purpose of this course is to review the process for performing a complete physical exam for adult patients

in the acute care setting.

After successful completion of this course, the participant will be able to:

1. Describe the details of performing a focused physical exam in an acute care setting.

2. Identify abnormal findings when conducting a head to toe assessment on your hospitalized patient.

3. Describe how to organize a routine physical assessment.

Introduction

Nurses are integral members of a multi‐disciplinary healthcare team. In an acute care setting, nurses often

have the responsibility and the privilege of performing a focused physical assessment for each of their

patients.

This initial assessment provides an important opportunity to evaluate and formulate a plan of care that is best

suited to meet your patients’ needs (Jarvis, 2012). Note that this course focuses on examination of the adult

patient in an acute care setting. The assessment of a pediatric or neonatal patient is specialized and is outside

the scope and purpose of this course.


Performing a methodical and focused physical examination will allow the nurse to detect obvious and subtle

changes in a patients’ health status.

The ability to recognize any changes in patient status will depend on the evaluator’s level of expertise and

knowledge of normal anatomy and physiology. In addition, the environment where the physical exam is to be

performed should support a quality exam.

A focused physical assessment begins with an initial survey of the patient and the surrounding environment.

When entering the patient’s room, note the patient’s general appearance and their response to your greeting.


It is important to maintain a confident and empathetic professional demeanor. If family members or friends

are present this is an opportune time to observe the type of social interactions that occur between the patient

and their significant others (Jarvis, 2012).

A systematic physical assessment remains one of the most vital components of patient care. A thorough

physical assessment can be completed within a time frame that is practical and should never be dismissed due

to time constraints (Zambas, 2010).


The Environment

The nurse should closely observe the environment of the patient to identify any potential safety hazards such

as:

Poor lighting.

Objects on the floor.

Wheelchairs or furniture that is moveable or unlocked.

Excessive clutter.

Accessibility to mobility aids.

Other considerations include ensuring that the patient has access to:

Clean eye‐glasses (as needed).

Properly fitting non‐slip footwear.

Personal belongings and call bell.

Urinal (for males).

In addition, the nurse should ensure that IV tubing and poles are out of walking area, and that the IV poles

move freely and are sturdy. The patient’s tubes and drains should not be a fall hazard.

Setting The Scene: Communication & Privacy

This initial introductory period is very valuable in building trust and establishing rapport, and provides clues to

your patient’s ability to comprehend health information and help you identify potential educational needs

(Jarvis, 2012). Communication during the physical must be respectful and performed in a culturally‐sensitive

manner. Privacy is vital, and the healthcare professional needs to be aware of posture, body language, and

tone of voice while interviewing the patient (Jarvis, 2012; Caple, 2011).

General Survey

Focus your attention on the patient. Perform a quick, general survey and explain to the patient the importance

of performing a focused physical assessment.

This initial general survey usually allows you to note the patient’s physical and mental status (alert, confused,

relaxed, anxious, disheveled, well‐groomed), the presence of IVs or dressings, and the type of equipment the

patient is using.

A brief scan of this equipment should indicate if it is functioning properly. If there is doubt about the correct

functioning of the equipment, attend to this situation immediately and explain what you are doing to the

patient. If there is doubt about the integrity of an IV or a dressing is not intact, this should also be corrected

(Jarvis, 2012; Altman, 2010).

Vital Signs


Vital signs must be reviewed in conjunction with the physical exam.

It is a good idea to consult your patient’s chart before you begin the assessment to review previous vital signs

and any other pertinent information specific to your patient’s status. Identification of trends in vital signs can

be crucial to identifying potential problems (such as steadily increasing or decreasing vital signs) (Jarvis, 2012;

Edmunds, Ward & Barnes, 2010).

When reviewing vitals, your patient’s temperature should be within normal range. Causes of high or low

temperatures should be investigated.

Heart rate or pulse should be within normal range. Rates vary according to age and patient history. Typically,

adults radial pulse rate should be between 60 and 100 beats per minute. The pulse should be regular.

Descriptions of pulse are weak or strong, with a regular or irregular beat. An irregular heart rate should be

counted for a full minute (Jarvis, 2012; Altman, 2010). See also section on extremities and pulse quality later in

module.

Respiration & Blood Pressure

You will also want to note the rate and depth of respirations. Again, respiratory rates vary according to age

and patient history. It is always important to know your patient’s baseline respiratory rate. A normal adult

respiratory rate is from 12 to 20, although some sources say 16‐24. Regardless, assess their rate and compare

to their baseline. Descriptions of respirations are normal (or easy), shallow, deep, labored, or noisy (Jarvis,

2012; Altman, 2010).

Finally, look at your patient’s blood pressure. Recall that the systolic reading reflects the pressure exerted by

the left ventricle during contraction. The diastolic reading reflects the pressure in the arteries when the heart

is at rest. The American Heart Association (AHA) report that a normal blood pressure reading is a systolic

blood pressure of less than 120 mmHg and a diastolic pressure of less than 80 mmHg.

Beginning from the age 20 and onwards, the American Heart Association recommends a blood pressure

screening at least once every 2 years, if blood pressure is less than 120/80 mm Hg (AHA, 2014).

Normal Range of Adult Vital Signs

Vital Sign Range

Pulse/heart rate 60‐100 beats/minute

Respiratory rate 12‐20 breaths/minute

Blood pressure Systolic: Less than 120mmHg

Diastolic: Less than 80mmHg

(Jarvis, 2012; Altman, 2010)


AHA Blood Pressure Categories

Blood Pressure Category Systolic

mm Hg (upper #)

Diastolic

mm Hg (lower #)

Normal Less than 120 and Less than 80

Prehypertension 120 ‐ 139 or 80 ‐ 89

High Blood Pressure

(Hypertension) Stage 1 140 ‐ 159 or 90 ‐ 99

High Blood Pressure

(Hypertension) Stage 2 160 or higher or 100 or higher

Hypertensive Crisis

(Emergency care needed) Higher than 180 or Higher than 110

Modified from the American Heart Association [AHA], (2014).

Test Yourself

Respiratory rates should be assessed in relation to:

1. Other patients

2. The patient’s own baseline rate ‐ Correct

3. Standard respiratory rates by age group

Pain Assessment

Conducting an in‐depth pain assessment will assist you in developing a comprehensive pain management plan.

If patients are able to communicate, it is important to incorporate verbal reports of pain using descriptions

and/or appropriate tools. Pain must be assessed and recorded in a manner that promotes reassessment. By

using the mnemonic PQRST, you can easily and confidently perform and document a comprehensive pain

assessment.


Use PQRST to assess each symptom and after any intervention to evaluate any changes or responses to

treatment (Jarvis, 2012):

P: Provoked or Palliative: What makes the pain better or worse?

Q: Quality: Describe the pain. Is it burning, shooting, aching, stabbing, crushing, etc?

R: Region or Radiation: Does the pain radiate to another body part?

S: Severity: On a scale of 1‐10, (10 being the worst) how bad is your pain? Another visual scale may be

appropriate for patients that are unable to identify with this scale.

T: Timing: Does it occur in association with something else? (e.g. eating, exertion, movement)

Pain Assessment and Reassessment

Due to the subjectivity of pain, the patient’s self‐report must be the standard by which pain is measured. A

systematic history of the pain and its associated factors provides the healthcare provider with a powerful

foundation to control the patient’s pain (Jarvis, 2012).

If your patient complains of pain during the initial assessment, do not withhold medications in order to

complete an entire assessment (follow your facility procedure for administration of pain medication). Keep in

mind, however, that assessment is the first step in satisfactorily managing a patient’s pain.

To evaluate the effectiveness of a treatment or medication, the patient’s response to the pain intervention

must also be reassessed (within your facility’s specific time frame).

A Comprehensive Review of Systems

As you perform your physical assessment, keep in mind that physical assessment findings will help to

determine the etiology of the diagnosis.

Begin by assessing the patient’s head and work your way to their toes, assessing different body systems as you

travel from head to toe.

Head Assessment

When inspecting the patient’s head, inspect and palpate (if necessary) the scalp, hair, and cranium. Note

lesions, tenderness of scalp, and condition of hair/hygiene. Inspect your patient’s facial expression and

symmetry. This will test the functioning of Cranial Nerve VII, which functions to control most of the muscles of

facial expression.

An acute facial nerve paralysis is usually manifested by facial paralysis. Bell's palsy is one type of idiopathic

acute facial nerve paralysis, which involves the facial nerve, and most likely results from viral infection and

also sometimes as a result of Lyme disease.

Facial Assessment

Voluntary facial movements, such as wrinkling the brow, showing teeth, frowning, closing the eyes tightly

(lagophthalmos), pursing the lips and puffing out the cheeks, all test the facial nerve. There should be no

noticeable asymmetry (Jarvis, 2012).


Pupillary Assessment

Inspect external eye structure, conjunctivae, sclera, corneas, and irises while shining a penlight at the patient’s

pupils. Note any discoloring or discharge.

You will need to assess each pupil’s size, shape, and symmetry.

Each pupil should constrict briskly when a light is shined into the eye. Each pupil should also have consensual

light reflex. This means that when you shine the penlight into the right eye, the left eye constricts and vice

versa. When assessing PERRLA (Pupils Equal Round and Reactive to Light and Accommodation), note how

many mm before and after constriction with light, and how long for the reaction. The best description for

reaction is in seconds rather than “normal” or “sluggish,” which can be subjective (D’Amato & Hartlage, 2008).

Inspection of Ears, Nose, Mouth & Throat

The ears, nose, mouth, and throat should be inspected as well at this time. Examine behind the ears for

redness and skin condition, check for discharge from ears, response of patient (hearing acuity), and general

symmetry. Inspect the mouth, looking at mucosa and teeth. This can identify if the patient needs oral care.

Unless there is an abnormality, no further examination of these sites is needed.

Neck Inspection & Palpation

Inspect the neck for symmetry, lumps, and pulsations.

If necessary, palpate cervical lymph nodes.

Inspect and palpate the carotid pulses. Do not occlude both carotid arteries at the same time.

Neck Auscultation

If the patient has a history of cardiovascular disease, you may want to auscultate the carotid arteries for the

presence of bruits by using the bell of your stethoscope. Bruit is French for noise, and is an abnormal sound

sometimes heard over an artery or vascular channel, when there is turbulent blood flow. Listening for a bruit

in the neck is a simple, safe, and inexpensive way to screen for stenosis of the carotid artery (Edmunds, Ward

& Barnes, 2010; Jarvis, 2012).

Test range of motion and muscle strength against resistance (tests cranial nerve XI) by having the patient

perform shoulder shrugs while you press down on their shoulders. Rate their strength on a scale of 0‐5 (Jarvis,

2012).

Test Yourself:

The presence of bruits in the carotid artery may suggest:

1. Stenosis

2. Turbulent blood flow

3. Both of the above – Correct!


Thorax

Inspection: Inspect the chest for asymmetry, deformity, or increased anterior‐posterior (AP) diameter and

confirm that the trachea is near the midline. A normal AP diameter is approximately 2:1.

Observe the rate, rhythm, depth, and effort of breathing. Note whether the expiratory phase is prolonged.

Listen for obvious abnormal sounds with breathing such as wheezes. Observe for retractions and use of

accessory muscles (Jarvis, 2012).

Palpation: Palpate for symmetric expansion. Identify any areas of tenderness or deformity by palpating the

ribs and sternum (Jarvis, 2012).

Lung Auscultation: Listen to breath sounds noting adventitious (abnormal) sounds. When auscultating, ensure

your room is quiet, auscultate over bare skin, and listen to one sound at a time. Your bell or diaphragm should

be placed on your patient’s skin firmly enough to leave a slight ring on their skin when removed. Be aware that

your patient’s hair may also interfere with true identification of certain sounds (Altman, 2010; Jarvis, 2012).

Click here to listen to normal lung sounds, crackles and wheezes, using The Auscultation Assistant®. (Make

sure the volume is turned up on your computer.)

Assessment of Lung Sounds

Begin with auscultation of the front of the chest, followed by auscultation of the chest from the back. To

assess lung sounds, place the diaphragm of your stethoscope on number one on the far right of the front of

the chest, and follow the numbers according to the pattern shown. Remember to also listen to the right side

of the chest, mid‐axillary line, in order to hear the right middle lobe (Altman, 2010; Jarvis, 2012). You should

expect to hear 3 normal types of breath sounds in the adult and older child:

Bronchial breath sounds (B) are loud, harsh and high pitched sounds, heard predominantly over the

trachea, bronchi (between clavicles and midsternum) and over the main bronchus.

Bronchovesicular (BV) breath sounds are blowing sounds with moderate intensity and pitch, and are

heard over large airways, on either side of the sternum, at the angle of Louis and between the

scapulae.

Vesicular (V) breath sounds are soft, breezy, low pitched sounds heard over the peripheral lung area,

and are most clearly heard at the base of the lungs.


Lung Sounds

Test Yourself:

Normal breath sounds include:

1. Bronchial sounds – Correct!

2. Occasional crackles

3. Intermittent stridor

Cardiac Assessment

After auscultating the lung fields, focus your attention on the heart.


Inspection: Inspect the precordium for pulsations or a heave.

Cardiac Auscultation

Before you begin your auscultation of the precordium, preface your exam by telling the patient you will be

listening in many different places for what might seem a long time. Let your patient know that this does not

indicate that anything is wrong.

Then identify the areas you need to auscultate. You may want to inch your stethoscope in a “Z‐pattern” across

the precordium, from the base of the heart to the apex.

Normal Heart Sounds

The first heart sound (S1): Occurs with the closure of the AV valves and signals the beginning of systole.

Although you can hear S1 sounds all over the precordium, it is loudest at the apex. S1 is easily recognized as

the “lub” sound.

The second heart sound (S2): Occurs with the closure of the semilunar valves and signals the end of systole.

This sound is loudest over the base, and is easily recognized as the “dub” sound.

The third heart sound (S3): Is normally not heard, as it occurs during early ventricular filing. When the

ventricles are resistant to filling, a S3 sound may be heard as ventricular filling causes vibrations that can be

heard over the chest.

The fourth heart sound (S4): Occurs at the end of diastole, when the ventricle is resistant to filing. The atria

contract and push blood into a non‐compliant ventricle during presystole. This creates vibrations that are

heard as S4 sounds, just before S1.

(Jarvis, 2012).

Auscultating Rate and Rhythm

Auscultate apical rate and rhythm. Note any abnormal heart sounds, their anatomical location, and their

timing in relation to S1 and S2. At least one assessment should include both the diaphragm and the bell of

your stethoscope to identify any abnormal sounds. Remember that murmurs occur when there is turbulence

in the blood flow, which could be from numerous causes. Hearing a murmur is only one piece of the puzzle to

assessment (Edmunds, Ward & Barne, 2010; Jarvis, 2012).

Click here to listen to rubs, gallops and continuous murmurs using The Auscultation Assistant®.

Test Yourself:

An S3 heart sound can be heard when the:

1. Atria fill

2. Semilunar valves close

3. Ventricles are resistant to filling – Correct!


Male and Female Breasts

When examining the thorax it is also important to inspect the breasts of male and female patients.

The male breast should be assessed for any ulcerations or sores, edema, or nodules. Although rare, men can

be at risk for developing breast cancer, especially if a mother or sister has been diagnosed with the disease

(Jarvis, 2012).

Female Breast Examination

Females require a much more in‐depth exam related to the larger amount of glandular tissue that is

considered to be a potential site for the growth of cancer cells (Altman, 2010). Female breasts should be

examined for size, symmetry, edema, inflammation, lesions and the presence of any discharge. Lymph nodes

are not normally palpable in males or females. Any masses that are detected should be palpated to determine

location, tenderness, mobility, consistency, diameter, shape and definition of boundaries (Altman, 2010;

Jarvis, 2012).

When performing your inspection keep in mind that breast tissue changes with age. Anticipate that older

patients will have less elasticity of tissue that can result in pendulous breasts or shrunken nipples.

Also examine the skin underneath breast tissue. Creases provide a warm, moist environment that can grow

yeast and bacteria (Jarvis, 2012).

Test Yourself:

Breast tissue does not change with age.

1. True

2. False – Correct!

Abdomen

Inspect the abdomen for previous surgical scarring, bulges, masses, hernias, ascites, or pulsations.

Auscultate for bowel sounds after inspection, but prior to percussion and palpation, since percussion and

palpation can increase peristalsis, which can give a false interpretation of bowel sounds. Divide the abdomen

into 4 quadrants, by drawing an imaginary line vertically and horizontally across the abdomen, to intersect at

the umbilicus.

Right Upper Quadrant (RUQ):

Liver

Gallbladder

Duodenum

Head of pancreas

Right kidney and adrenal gland

Hepatic flexure of colon

Part of the ascending & transverse colon


Left Upper Quadrant (LUQ):

Stomach

Spleen

Left lobe of liver

Body of pancreas

Left kidney & adrenal gland

Splenic flexure of the colon

Part of the transverse and descending colon

Right Lower Quadrant (RLQ):

Cecum

Appendix

Right ovary and tube

Right ureter

Right spermatic cord

Left Lower Quadrant (LLQ):

Part of descending colon

Sigmoid colon

Left ovary and tube

Left ureter

Left spermatic cord

Auscultation should begin in the right lower quadrant. If bowel sounds are not heard, in order to determine if

bowel sounds are truly absent, listen for a total of five minutes (Jarvis, 2012).

Abdominal Percussion

Percuss the abdomen to assess the relative density of abdominal contents, to locate organs and to screen for

abnormal fluid or masses (Jarvis, 2012). Begin with light percussion in all 4 quadrants, and progress in a

clockwise manner. Findings may include:

Tympany (Hollow drum‐like sound produced when a gas‐containing cavity is tapped): Should be

present in all 4 quadrants as air in the intestines rise to the surface when the patient is supine.

Dullness: Occurs over a distended bladder, adipose tissue or a mass.

Hyperresonnance (Low‐pitched, booming sound): Present when there is gaseous distention.

Abdominal Palpation

Lastly, palpate the abdomen lightly then deeply noting any muscle guarding, rigidity, masses, or tenderness.


Palpate tender areas last. Only if indicated, palpate the liver margins, the spleen or the kidneys and percuss

the abdomen for general tympany, liver span, splenic dullness, costovertebral angle tenderness, presence of

fluid wave, or shifting dullness with ascites (Jarvis, 2012).

Male and Female Genitalia

Inspect the patient’s genitalia. Make note of any abnormalities such as redness, swelling or discharge. Also

examine the skin creases around the genitalia for redness, tenderness, and odor (Jarvis, 2012).

In the acute care setting, the physician or an advanced practitioner may ask for your assistance collecting

swabs to be sent to the lab for testing. Remember that many individuals (male and female) may be very

uncomfortable with this part of the exam.

Ensure privacy and provide a clear explanation of why and what you are doing. Allow the patient time to ask

questions. Some cultures might require that a family member be present or that an exam be performed by a

nurse or physician of the same gender as the patient (Altman, 2010; Jarvis, 2012).

Elimination

While performing an inspection of the patient’s genitalia, examine the urinary meatus. Note redness, swelling

or discharge. Ask the patient about the color, odor, and amount of urine the patient is producing. Most often,

patients with renal or urinary problems will complain about frequent urination, difficult or painful urination, or

blood in their urine. Their 24‐hour intake should be comparable to their 24‐hour output. Check their flow

sheet and assess their 24‐hour intake and output.

Compare their weight today with yesterday’s weight. Weight should not significantly increase from day to day

unless there is fluid accumulation or decrease from day to day unless there has been a prescribed therapy

aimed at this.

You will also want to note the patient’s last bowel movement, its character, and ask the patient if there are

any difficulties with producing bowel movements (Jarvis, 2012).

Palpation & Assessment of Upper Extremities

Palpate the peripheral arteries of the upper extremities, namely the brachial and radial arteries. Note the

contour and amplitude of each pulsation. These should feel similar bilaterally. As you move further away from

the core of the body, you may notice that the contour or upstroke of the pulsation is less rapid. This is normal.

It is important, however, that the arteries have similar strength bilaterally.

Inspect and assess upper extremity strength, symmetry and range of motion for the shoulders, elbows, wrists,

and hands. Test the strength and symmetry of a hand grip. Assess the strength and symmetry of the bicep and

tricep muscles by asking the patient to extend their elbows (triceps) against your resistance, then flex their

elbows (biceps) against your resistance (Altman, 2010; Jarvis, 2012).

Inspection & Palpation of Lower Extremities

Inspect the patient’s skin for warmth, moisture and edema. Cool, clammy skin results from vasoconstriction;

warm, moist skin results from vasodilation.


Note any edema. Edema can result from many disease processes including heart failure, liver failure, or by

venous insufficiency, varicosities, and thrombophlebitis. Inspect your patient’s hair distribution on their skin of

the lower extremities. Lack of hair may indicate arterial insufficiency.

Capillary refill should be tested bilaterally by pressing the nails on fingers. An expected refill with blanching is

less than 2 seconds for adults (Jarvis, 2012).

Inspection & Assessment of Lower Extremities

Palpate the peripheral arteries of the lower extremities. These include the femoral, popliteal, dorsalis pedis

and posterior tibial arteries. It may be necessary to only palpate the most distal arteries, namely the dorsalis

pedis and posterior tibial. To locate the dorsalis pedis, palpate the artery on top of the foot on the side of the

big toe. To palpate the posterior tibial artery, find the bony prominence (the medial malleolus) on the medial

ankle. Roll your finger towards the angle of the heel, and feel for the pulse. If they are present you can assume

the more central arteries are intact.

Note the contour and amplitude of each pulsation. These should feel similar bilaterally. As you move away

from the core of the body, remember that the contour or upstroke of the pulsation is less rapid and this is

normal. It is still important, however, that the arteries have similar strength bilaterally (Altman, 2010; Jarvis,

2012).

Extremities: Pulse & Muscle Strength

Inspect and assess lower extremity strength and range of motion for the hips, knees, ankles, and feet. Ask the

patient to flex their legs at the hips. Provide some resistance to this. Examine their strength against resistance

when they extend their knees (quadriceps) and dorsiflex and plantarflex their feet. Again, note strength and

symmetry of these muscle groups. Capillary refill should also be assessed bilaterally on the feet, and compared

with the time for return with upper extremities (Jarvis, 2012).

Consult this edema scale to correctly and objectively rate your patient’s edema.

Hogan (2013)

Test Yourself:

Your patient has pitting edema that disappears within a few seconds. This is considered:


1. 1+

2. 2+ ‐ Correct!

3. 3+

Assessing Peripheral Pulses and Muscle Strength

This table will help you rate the strength of your patient’s peripheral pulses.

Consult this scale to objectively rate your patient’s muscle strength.

Skin Assessment

Skin assessment can be performed throughout the physical examination. As each body system is examined,

assessment of the skin can be incorporated into findings (Jarvis, 2012).

When assessing the skin, EXAMINE the following:

General pigmentation (evenness, appropriate for heritage)

Systemic color changes (pallor, erythema, cyanosis, jaundice)

Freckles and moles (symmetry, size, border, pigmentation)

Temperature (hypothermia, hyperthermia)

Moisture and texture (diaphoresis, dehydration, firm smooth texture)

Edema (location and degree)

Bruising (location, pattern, consistent with history – especially in at risk populations)

Lesions (color, elevation, pattern or shape, size, location, exudates)

Hair (normal color, texture, distribution)

Nails (shape, contour, color)


Remember that skin breakdown is a common problem with ill and hospitalized patients. Skin

assessment is vital to identify areas of vulnerability in the prevention of pressure ulcers (Jarvis, 2012).

Wound Assessment

If any wounds or alterations in skin integrity were noted during your exam, you will want to go back and pay

closer attention to that site(s). This assessment involves identification of the cause of the wound (i.e. is it

venous, arterial, diabetic, traumatic, or pressure‐related?), the location, size, and depth of the wound.

Assessment must also include assessing for any undermining or dead space, the type of tissue present, the

quality and amount of exudates, the presence of infection, the condition of the wound margins, and an

evaluation of any past and current treatments.

Additionally, if the wound is thought to be a pressure wound, you should stage it. Pictures of wounds are also

an important component of documentation. Consult your facility’s policies and procedures for wound

documentation and treatment (Altman, 2010; Jarvis, 2008).

For a more in‐depth review of skin wounds, please see RN.com’s Assessment Series Course: Skin Anatomy,

Physiology & Assessment.

Stage 1

Major Descriptor

Non‐blanchable erythema of intact skin ‐ do not confuse with reactive hyperemia (a transient increase in

blood flow following a brief period of occlusion, such as arterial occlusion).

Characteristics

• May be either warm or cool to the touch

• May be boggy or firm to the touch

• Pain and itching may be present

Special Considerations

Fair Skinned Persons: Ulcers appear as an area of persistent redness.

Darker Skin: Ulcer may appear with persistent red, blue, or purple.

Stage 2

Major Descriptor

Partial thickness skin loss involving epidermis and/or dermis

Characteristics

• Superficial wound

• Shallow crater



May only appear as a blister or abrasion

Stage 3

Major Descriptor

Full‐thickness skin loss involving damage or necrosis of subcutaneous tissue

Characteristics

A Stage 3 wound is usually described as a deep crater.


Sinus tracts extending into adjacent tissue may or may not be present.

Stage 4

Major Descriptor

Full thickness skin loss with extensive destruction, tissue may or may not be present. Muscle and bone injury

may be involved.

Characteristics

• Necrotic or eschar tissue may be noted

• Muscle, bone, and other supporting structures may be visible


May affect joint, tendons and/or ligaments.

Sinus tracts also may be associated with Stage IV pressure ulcers.

Staging of Pressure Ulcers

Pressure ulcers can be classified according to 4 different stages of infiltration:


Test Yourself:

A Stage 3 pressure ulcer will involve injury to:

1. Muscle and bone

2. Subcutaneous tissue – Correct!

3. The epidermal and dermal layers

Conclusion

As the patient’s nurse, you must critically analyze all of the data that you collect from a focused physical

assessment.

Once you have obtained all of the patient’s information, the data must be synthesized into relevant problem

focuses and a plan of care devised that is based on the synthesis of the information you have collected.

In addition, as the plan of care is being carried out, reassessments must occur on a prescheduled and as

needed basis. The frequency of these reassessments is unique to each patient and depends on their health

status. Determining how often to reassess your patient is a critical thinking skill that comes with patient care

experience.

Performing a focused physical assessment is an invaluable tool that assists the caregiver to individualize and

provide the best quality care available.

References

Altman, G.B. (2010). Fundamental and advanced nursing skills, (3rd ed.). Clifton Park, NY:

Delmar.

American Heart Association [AHA], (2014). Understanding Blood Pressure. Retrieved from: http://www.heart.org/HEARTORG/Conditions/HighBloodPressure/AboutHighBloodPressure/Understanding‐Blood‐Pressure‐Readings_UCM_301764_Article.jsp

Caple, C. (2011). Physical assessment: Performing‐ cultural considerations. Glendale, CA:

Cinahl Information Systems.

Colorado State University Auscultation Library. (2014) .Auscultation library. Retrieved

July 24, 2014 from: http://www.cvmbs.colostate.edu/clinsci/callan/breath_sounds.htm

D’Amato, R., & Hartlage, L. (2008). Essentials of neuropsychological assessment:


Treatment planning for rehabilitation (2nd ed). NY: Springer Publishing.

Edmunds, L., Ward, S., & Barnes, R. (2010). The use of advanced physical assessment

skills by cardiac nurses. British Journal of Nursing, 19(5), 282‐287.

Hogan, M. (2013). Medical‐Surgical Nursing WITH Pearson Reviews & Rationales (3nd Ed.). Salt Lake City: Prentice Hall.

Jarvis, C. (2012). Physical examination and health assessment, (6th ed.). St. Louis: W.B. Saunders.

Mosby Company. (2013). Mosby’s medical dictionary (9th ed.). New York: Elsevier.

Venes, D. (ed.) (2013). Tabers® cyclopedic medical dictionary, (22nd ed.). Philadelphia: F.A. Davis Co.

Zambas, S.I. (2010). Purpose of the systematic physical assessment in everyday practice:

Critique of a “sacred cow”. Journal of Nursing Education, 49(6), 305‐310.

© Copyright 2004, AMN Healthcare, Inc.

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